Provider Demographics
NPI:1487633228
Name:KIM, MARK Y (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8235
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:716-817-1726
Practice Address - Street 1:3900 N BUFFALO ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1842
Practice Address - Country:US
Practice Address - Phone:716-656-4804
Practice Address - Fax:716-250-5933
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2020-11-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY234385-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0412847OtherIHA
NY00027258001OtherUNIVERA
NY02680335Medicaid
NY000528214001OtherHEALTH NOW
NM161000580OtherEMPIRE PLAN
NYI36167Medicare UPIN